Elsevier

Journal of Surgical Education

Volume 76, Issue 3, May–June 2019, Pages 756-761
Journal of Surgical Education

ORIGINAL REPORTS
Health Advocacy Competency: Integrating Social Outreach into Surgical Education

https://doi.org/10.1016/j.jsurg.2018.11.006Get rights and content

Objective

Being a strong health advocate is recognized as being an important part of being a good surgeon. Residency training programs have struggled with teaching health advocacy beyond didactic sessions, and in a way that encourages trainees to incorporate changes into their practice. This curriculum development aimed to incorporate reflective practice to encourage patient compassion and advocacy.

Design

Community service was incorporated as a mandatory component of a postgraduate surgical training program. Residents participated in a community service activity, and reflected upon their learning with a presentation to their peers.

Participants

Mandatory advocacy curriculum for all 67 first and second year surgical residents. Sixty-four residents chose to participate in a community service activity. Forty-six residents completed year end evaluations on the curriculum.

Results

Seventy percent of outreach activities were medically related, and 30% nonmedical. Most residents felt that the amount of work required to complete this project was reasonable (90%), and learned from their experiences (76%). Residents who participated in medically related projects self-described greater learning from their activity (93%), and from watching their peer presentations (79%). These trainees were also more likely to alter their patient management based on their experiences (68%). Trainees who participated in nonmedically related outreach projects were less likely to self-reflect learning from their experiences. Despite mandatory teaching in health advocacy, trainees are often unaware of this teaching within their curriculum.

Conclusions

A mandatory outreach project in residency can encourage trainees to reflect on their volunteer activities as a physician and how it impacts their patient's health. Academic departments should try to encourage volunteerism within their trainees by providing opportunities for residents to participate in outreach activities related to their specialty.

Introduction

Being a surgeon requires more than medical knowledge and expertise. The CanMEDS Framework was brought into Canadian postgraduate medical training to improve patient care by ensuring a comprehensive medical education.1 CanMEDs categorizes postgraduate medical education into 6 different roles/competencies a physician must display in order to be a good medical expert. These roles are: communicator, collaborator, scholar, manager, professional, and health advocate. Since their introduction, similar roles have been adopted by medical training organizations around the world, including the ACGME competencies.2 Among the CanMEDS roles, the role of health advocate is often considered particularly challenging to define, teach, learn, and evaluate.3-5 However, improving health advocacy education has the potential to not only improve patient care and public health, but to also increase physician professionalism and ethics.6 It encourages clinicians to view patients with a system based approach, rather than solely within a clinical disease framework.

Many residency programs have attempted to incorporate health advocacy curricula into formal teaching. Some common methods include didactic modules focused on the social determinants of health, as well as advocacy-specific rotation.7, 8 These formats demonstrate increased knowledge, however each comes with its own challenges. Didactic lectures address the theoretical aspect of advocacy, but do not necessarily translate into clinical practice. Outreach and advocacy rotations allow trainees to see many social issues applied within their clinical setting, but may not be practical for all training programs due to location or subspecialty of training. Surgical specialties may be challenged to organize an outreach rotation due to clinical volumes and resource requirements. As such, surgeons may find additional challenges in incorporating health advocacy within their curriculum. A survey of surgeons in the Netherlands rated health advocacy as the least important CanMEDs role, but also the most difficult one to teach and assess.4

International rotations in low resource countries also offer a great opportunity to learn about health advocacy. 9 However, these rotations may not be accessible to all trainees, and the cultural and geographical distance setting may not translate to local practice.

Even when incorporated into curricula, advocacy rotations or lectures usually occur only once during a multi-year training program and covers a narrow definition of advocacy. Work based health advocacy is often also limited to those aspects that are most likely to be observed in a hospital or clinical setting – advocating for the patient who presents for clinical care.

However, health advocacy extends beyond the hospital setting, and must include responding to needs of the community and population. Interacting with patients outside of the clinical environment provides the opportunity to see patients in a setting where they are people, with less of the power differential that exists within the clinical setting. Providing opportunities to foster health advocacy beyond a one-on-one clinical interaction is challenging to accomplish within the workplace.

Community service activities could provide a platform to learn about challenges many in society face. Minimum community service hours are common in high school curricula, and volunteering is universal in premed students. There is also recognition of the need to promote community service in undergraduate medical education. However, community outreach often decreases as individuals progresses through their medical training.10 Volunteering during residency can allow trainees to view their activities through the lens of a physician, but at the same time provide an opportunity to see their patient as a person, with the many facets to their health issues beyond the disease process itself.

The goal of our curriculum was to teach health advocacy through an accessible curriculum initiative focused on reflective experiential learning. Ideally, this would be something feasible to continue throughout one's training, and that allowed for advocacy to be viewed from several different perspectives.

Section snippets

Methods

We implemented a mandatory community outreach initiative as part of the Surgical Foundations (SF) program at the University of Ottawa. SF is a mandatory 2 year curriculum for all junior surgical trainees (residents) in Canada. SF runs in tandem with a trainee's surgical specialty training. These specialties include cardiac surgery, general surgery, neurosurgery, obstetrics and gynecology, orthopedic surgery, otolaryngology, plastic surgery, urology, and vascular surgery.

All residents enrolled

Results

Sixty-seven surgical trainees were enrolled in the SF program for the 2014 to 2015 academic year. Sixty-four trainees completed an outreach activity while 3 chose to write a reflective paper. Upon review of the year-end presentations, 59% of activities were specialty related, 11% were other medically related, and 30% nonmedical in nature, as categorized by the authors. Specialty related projects included a plastic surgery trainee volunteering at a breast reconstruction awareness event.

Conclusions

This innovative outreach curriculum aimed to teach about health advocacy to postgraduate trainees through experiential learning. The long term goal is for this initiative to have a lasting impact and a culture shift on the perception of social outreach. Though only first and second year trainees participate in SF, some trainees can hope continue their involvement throughout their training, and appreciate that outreach and health advocacy initiatives are just as important as the other physician

Acknowledgments

The authors would like to thank the AMS Foundation for the support of our surgical outreach and health advocacy initiatives, and Ms Laura Gerridzen for the implementation of our many initiatives in the Surgical Foundations curricula.

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Cited by (0)

Funding: Dr. Yvonne Ying was supported by the Associated Medical Services Inc. through an AMS Phoenix Fellowship.

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